A mixed-methods investigation of the extent to which routinely collected information can help evaluate the implementaion of screening and brief alcohol interventions in primary health care

PhD ThesisBackground: UK health policy has sought to encourage alcohol screening and brief intervention (ASBI) delivery in primary care, including via pay-for-performance (P4P) schemes. To measure the impact of such policies, a range of data exist, including General Practitioner (GP) Read codes, which record all clinical activity. However, previous studies have highlighted the difficulties of using Read code data for evaluation purposes, with concerns around the distorting effect of P4P on healthcare recording. Against this background, this research investigated whether Read code data can be used to provide a meaningful measure of ASBI implementation in primary care. Methods: Sequential mixed methods design, comprising: (1) systematic literature review to identify what factors influence the recording of routine clinical data by UK primary care physicians; (2) analysis of ASBI Read code data from 16 GP practices in North East England; (3) 14 GP interviews to explore the barriers and facilitators affecting their ASBI recording. Results: (1) Multiple factors shape primary care physicians’ recording of routine data, including structural influencers (such as the design and resourcing of the coding system), and psychosocial factors (including patient characteristics and physicians’ perspectives on their role as care-givers). (2) 287 Read codes exist to record alcohol- related activity however only a small minority are used regularly, generally relating to the identification of alcohol use disorders. Whilst many unused Read codes are associated with relatively rare alcohol conditions, a significant number relate to duplicate or outmoded terminology. Overall, practices associated with higher recorded rates of key ASBI service indicators were signed up to P4P schemes. (3) GP interviews suggested that across all practices, nurse-administered ASBI components were most likely to be provided and coded consistently, with GP-delivery and recording activity far more ad hoc. Conclusion: Whilst routine data may be a valid indicator of more successfully embedded ASBI activity in UK primary healthcare following the introduction of P4P schemes, measuring the impact on delivery at GP level remains challenging due to the deficiency of the available Read code data across a number of quality dimensions.ESRC UKCR

Using primary care databases for addiction research:An introduction and overview of strengths and weaknesses

Primary care databases extract and combine routine data from the electronic patient records of various participating practices on a regular basis. These databases can be used for innovative and relevant addiction research, but such use requires a thorough understanding of how data were originally collected and how they need to be processed and statistically analysed to produce sound scientific evidence. The aims of this paper are therefore to (1) make a case for why primary care databases should be considered more frequently for addiction research; (2) provide an overview of how primary care databases are constructed; (3) highlight important methodological and statistical strengths and weaknesses of using primary care databases for research; and (4) give practical advice about how a researcher can get access to databases. Three major primary care databases from the UK serve as examples: Clinical Practice Research Datalink (CPRD), The Health Improvement Network (THIN), and QResearch

Impact of financial incentives on alcohol intervention delivery in primary care: a mixed-methods study

Background Local and national financial incentives were introduced in England between 2008 and 2015 to encourage screening and brief alcohol intervention delivery in primary care. We used routine Read Code data and interviews with General Practitioners (GPs) to assess their impact. Methods A sequential explanatory mixed-methods study was conducted in 16 general practices representing 106,700 patients and 99 GPs across two areas in Northern England. Data were extracted on screening and brief alcohol intervention delivery for 2010-11 and rates were calculated by practice incentive status. Semi-structured interviews with 14 GPs explored which factors influence intervention delivery and recording in routine consultations. Results Screening and brief alcohol intervention rates were higher in financially incentivised compared to non-incentivised practices. However absolute rates were low across all practices. Rates of short screening test administration ranged from 0.05% (95% CI: 0.03-0.08) in non-incentivised practices to 3.92% (95% CI: 3.70-4.14) in nationally incentivised practices. For the full AUDIT, rates were also highest in nationally incentivised practices (3.68%, 95% CI: 3.47-3.90) and lowest in non-incentivised practices (0.17%, 95% CI: 0.13-0.22). Delivery of alcohol interventions was highest in practices signed up to the national incentive scheme (9.23%, 95% CI: 8.91-9.57) and lowest in non-incentivised practices (4.73%, 95% CI: 4.50-4.96). GP Interviews highlighted a range of influences on alcohol intervention delivery and subsequent recording including: the hierarchy of different financial incentive schemes; mixed belief in the efficacy of alcohol interventions; the difficulty of codifying complex conditions; and GPs’ beliefs about patient-centred practice. Conclusions Financial incentives have had some success in encouraging screening and brief alcohol interventions in England, but levels of recorded activity remain low. To improve performance, future policies must prioritise alcohol prevention work within the quality and outcomes framework, and address the values, attitudes and beliefs that shape how GPs’ provide care

Protein-protein interactions involving erbA superfamily receptors: through the TRAPdoor

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/29320/1/0000385.pd

Exploring high mortality rates among people with multiple and complex needs: a qualitative study using peer research methods

Objective To explore the perceived reasons underlying high mortality rates among people with multiple and complex needs.Design Qualitative study using peer research.Setting North East of England.Participants Three focus group discussions were held involving (1) people with lived experience of multiple and complex needs (n=5); (2) front-line staff from health, social care and voluntary organisations that support multiple and complex needs groups (n=7); and (3) managers and commissioners of these organisations (n=9).Results Findings from this study provide valuable perspectives of people with multiple complex needs and those that provide them with support on what may be perceived factors underlying premature mortality. Mental ill health and substance misuse (often co-occurring dual diagnosis) were perceived as influencing premature mortality among multiple and complex needs groups. Perceptions of opportunities to identify people at risk included critical life events (eg, bereavement, relationship breakdown) and transitions (eg, release from prison, completion of drug treatment). Early prevention, particularly supporting young people experiencing adverse childhood experiences, was also highlighted as a priority.Conclusion High mortality in multiple and complex needs groups may be reduced by addressing dual diagnosis, providing more support at critical life events and investing in early prevention efforts. Future interventions could take into consideration the intricate nature of multiple and complex needs and improve service access and navigation

Identification and analysis of low-molecular-weight dissolved organic carbon in subglacial basal ice ecosystems by ion chromatography

Determining the concentration and composition of dissolved organic carbon (DOC) in glacial ecosystems is important for assessments of in situ microbial activity and contributions to wider biogeochemical cycles. Nonetheless, there is limited knowledge of the abundance and character of DOC in basal ice and the subglacial environment and a lack of quantitative data on low-molecular-weight (LMW) DOC components, which are believed to be highly bioavailable to microorganisms. We investigated the abundance and composition of DOC in basal ice via a molecular-level DOC analysis. Spectrofluorometry and a novel ion chromatographic method, which has been little utilized in glacial science for LMW-DOC determinations, were employed to identify and quantify the major LMW fractions (free amino acids, carbohydrates, and carboxylic acids) in basal ice from four glaciers, each with a different type of overridden material (i.e. the pre-entrainment sedimentary type such as lacustrine material or palaeosols). Basal ice from Joyce Glacier (Antarctica) was unique in that 98% of the LMW-DOC was derived from the extremely diverse free amino acid (FAA) pool, comprising 14 FAAs. LMW-DOC concentrations in basal ice were dependent on the bioavailability of the overridden organic carbon (OC), which in turn was influenced by the type of overridden material. Mean LMW-DOC concentrations in basal ice from Russell Glacier (Greenland), Finsterwalderbreen (Svalbard), and Engabreen (Norway) were low (0–417nMC), attributed to the relatively refractory nature of the OC in the overridden palaeosols and bedrock. In contrast, mean LMW-DOC concentrations were an order of magnitude higher (4430nMC) in basal ice from Joyce Glacier, a reflection of the high bioavailability of the overridden lacustrine material (> 17% of the sediment OC comprised extractable carbohydrates, a proxy for bioavailable OC). We find that the overridden material may act as a direct (via abiotic leaching) and indirect (via microbial cycling) source of DOC to the subglacial environment and provides a range of LMW-DOC compounds that may stimulate microbial activity in wet subglacial sediments

From the Trenches: Cross-campus Digital History Collaboration

In September 2015, our team launched The First World War Letters of H.J.C. Peirs (www.jackpeirs.org), a digital history initiative built on collaboration between faculty, students, and library staff. The project is founded on amazing primary source material, but with limited financial support and little dedicated staff time. We leveraged the creativity and hard work of our team members to build a website that is maintained by students and enhanced whenever possible with features and commentary from faculty and staff. Members of #TeamPeirs will discuss the evolution of the project, the nature of our collaboration, and the intersection of audiences we have discovered.In September 2015, our team launched The First World War Letters of H.J.C. Peirs (www.jackpeirs.org), a digital history initiative built on collaboration between faculty, students, and library staff. The project is founded on amazing primary source material, but with limited financial support and little dedicated staff time. We leveraged the creativity and hard work of our team members to build a website that is maintained by students and enhanced whenever possible with features and commentary from faculty and staff. Members of #TeamPeirs will discuss the evolution of the project, the nature of our collaboration, and the intersection of audiences we have discovered

Scaling-up primary health care-based prevention and management of heavy drinking at the municipal level in middle-income countries in Latin America: Background and protocol for a three-country quasi-experimental study.

Background: While primary health care (PHC)-based prevention and management of heavy drinking is clinically effective and cost-effective, it remains poorly implemented in routine practice. Systematic reviews and multi-country studies have demonstrated the ability of training and support programmes to increase PHC-based screening and brief advice activity to reduce heavy drinking. However, gains have been only modest and short term at best. WHO studies have concluded that a more effective uptake could be achieved by embedding PHC activity within broader community and municipal support. Protocol: A quasi-experimental study will compare PHC-based prevention and management of heavy drinking in three intervention cities from Colombia, Mexico and Peru with three comparator cities from the same countries. In the implementation cities, primary health care units (PHCUs) will receive training embedded within ongoing supportive municipal action over an 18-month implementation period. In the comparator cities, practice as usual will continue at both municipal and PHCU levels. The primary outcome will be the proportion of consulting adult patients intervened with (screened and advice given to screen positives). The study is powered to detect a doubling of the outcome measure from an estimated 2.5/1,000 patients at baseline. Formal evaluation points will be at baseline, mid-point and end-point of the 18-month implementation period. We will present the ratio (plus 95% confidence interval) of the proportion of patients receiving intervention in the implementation cities with the proportions in the comparator cities. Full process evaluation will be undertaken, coupled with an analysis of potential contextual, financial and political-economy influencing factors. Discussion: This multi-country study will test the extent to which embedding PHC-based prevention and management of alcohol use disorder with supportive municipal action leads to improved scale-up of more patients with heavy drinking receiving appropriate advice and treatment. Study status: The four-year study will start on 1 st December 2017

'I take my tablets with the whiskey':A qualitative study of alcohol and medication use in mid to later life

Background Concurrent alcohol and medication use can result in significant problems especially in mid to later life. Alcohol is often used instead of medication for a number of health-related conditions. This novel qualitative study explored concurrent alcohol and medication use, as well as the use of alcohol for medicinal purposes, in a sample of individuals in mid to later life. Methods Twenty-four interviews (12 men/12 women, ages 51–90 years) and three focus groups (n = 27, 6 men/21 women, ages 50–95 years) from three branches of Age UK and two services for alcohol problems in North East England. Results Older people in this study often combined alcohol and medication, frequently without discussing this with their family doctor. However, being prescribed medication could act as a motivating factor to stop or reduce alcohol consumption. Participants also used alcohol to self-medicate, to numb pain, aid sleep or cope with stress and anxiety. Some participants used alcohol to deal with depression although alcohol was also reported as a cause of depression. Women in this study reported using alcohol to cope with mental health problems while men were more likely to describe reducing their alcohol consumption as a consequence of being prescribed medication. Conclusions As older people often combine alcohol and medication, health professionals such as family doctors, community nurses, and pharmacists should consider older patients’ alcohol consumption prior to prescribing or dispensing medication and should monitor subsequent drinking. In particular, older people should be informed of the dangers of concurrent alcohol and medication use